Unexpected Human Fatality Associated with Bed Bug (Hemiptera: Cimicidae) Heat Treatment

Thermal insect treatments can be an effective method of controlling cryptic insect pests, particularly bed bugs, in residential settings. The treatments require high heat over a sustained timeframe. Residents are not present during treatment but return after completion. An unexpected death was investigated following heat treatment for bed bugs in the home of an elderly female, found with a postmortem axillary temperature of 106.2°F (41.2°C) approximately 8 h after returning home. The cause of death was classified as hyperthermia with a contributory cause of hypertensive cardiovascular disease. The manner of death was an accident. The decedent had medical history and medications that could have impaired her ability to dissipate heat. Furthermore, the air conditioning inside the residence was not functional following treatment. Recommendations including education regarding heat stroke and treatment, re‐entry timeframes, and/or temperature thresholds are suggested to reduce the risk of heat‐related injury or death in vulnerable populations.     

Sudden and unexpected death from pituitary tumor apoplexy

Pituitary tumor apoplexy refers to a clinical syndrome precipitated by the expansion of a pituitary adenoma by hemorrhage or infarction. Individuals may present with myriad signs, including sudden onset of severe headache, visual changes, altered mental status, cranial nerve palsies, and hormonal dysfunction. This disorder constitutes a medical emergency and warrants an expedited evaluation, diagnosis, and treatment to prevent the potential sequelae of permanent visual loss, endocrine abnormalities, or death. We report a case of sudden death from undiagnosed pituitary tumor apoplexy. The decedent was evaluated by medical personnel on three occasions in the week prior to her death for severe headache, nausea, vomiting, and photophobia. Postmortem examination demonstrated a hemorrhagic infarction of a pituitary adenoma with necrosis and expansion out of the sella turcica. The recognition of and treatment for a patient with pituitary tumor apoplexy requires a rapid multidisciplinary effort. Failure of prompt diagnosis may be fatal and require a medico-legal death investigation for sudden and unexpected death.     

Iatrogenic deaths following treatment for hypertrophic obstructive cardiomyopathy: case reports and an approach to the autopsy and death certification

Hypertrophic cardiomyopathy (HCM) is a disease process which results in a large, heavy heart, with hypertrophy of the interventricular septum (IVS) and left ventricle. HCM accounts for a significant number of cases of sudden cardiac death each year, most infamously in young athletes. The prevalence of the disease has increased over the past several years due to advances in clinical diagnosis and molecular genetic studies. Over this same period, new forms of treatment also have emerged. One such treatment is alcohol septal ablation (ASA). ASA is a procedure performed by a cardiologist, via cardiac catheterization, by injecting pure ethanol into selected arteries which supply the IVS, resulting in a targeted myocardial infarction. This infarct then retracts and forms a scar, decreasing the outflow obstruction and improving the patient's clinical symptoms.The authors report 2 cases of death following ASA treatment of HCM. The first, a 56-year-old male, had his ASA procedure 10 days prior to death. The second decedent, a 76-year-old female, had her procedure only 30 hours before death. These case reports are followed by a discussion about HCM, including pathology, treatments, and treatment-related pathology, before closing with a discussion about death certification in the cases presented and therapy-related deaths in general.     

Postbariatric surgery deaths, which fall under the jurisdiction of the coroner

Obesity has attained epidemic proportions in the United States, with more than 50% of adults classified as overweight or obese. If untreated, morbidly obese patients have a 1 in 7 chance of reaching normal life expectancy. The surgical treatment of obesity has emerged as the most effective treatment modality in long-term weight control and has become increasingly popular, with attendant postoperative complications and death. We performed a cross-sectional, coroner based, 2-year retrospective review of archival case records for decedents who died following bariatric surgery for the treatment of obesity to identify underlying causes of death and forensic characteristics of this cohort. Fifteen (0.5%) out of 3097 archival cases died following bariatric surgery, with approximately 73% of decedents dying within 6 months of surgery. The underlying causes of death in 80% of decedents were natural comorbidities of obesity, with cardiovascular diseases (33%) being the most frequent causes of death, followed by gastrointestinal diseases (20%), acute pulmonary thromboembolism (13%), and acute bacterial pneumonia (13%). The majority of decedents were white females who remained morbidly obese after bariatric surgery. Only 2 decedents died of direct inadvertent/accidental surgical complications.     

Fatal renal hemorrhage after extracorporeal shock wave lithotripsy

Renal hematoma is one of the most severe complications of extracorporeal shock wave lithotripsy (ESWL). ESWL is used in the noninvasive treatment of urinary calculosis. The shock waves can lead to capillary damage, renal parenchymal or subcapsular hemorrhage. We present a case with fatal complication and the result of the medico-legal evaluation. A 71-year-old woman was treated by ESWL, renal hematoma was detected during the clinical observation, and the patient died. The death occurred despite close clinical observation as a consequence of a rare complication of ESWL. The mechanism of death was hemorrhagic hypovolemic shock due to renal hemorrhage complications due to ESWL for treatment of renal calculi. This therapeutic complication is a known complication of appropriate treatment.     

Sudden Death from Cardiopulmonary Arrest on Arrival of a Patient with Pulmonary Tuberculosis: A Case Diagnosed by Postmortem CT and Autopsy

Sudden death due to massive hemoptysis during management of tuberculosis occurs in a considerable number of patients. However, when massive airway hemorrhage occurs in a patient in whom tuberculosis has not been confirmed and a blood is not apparent externally on the face/body, it is difficult to immediately identify the cause of death as airway obstruction by tuberculous bleeding in the airway. We encountered an 83‐year‐old Japanese woman with her medical history included treatment of tuberculosis in her 20s who was in cardiopulmonary arrest on arrival (CPAOA), and the cause of sudden death could not initially be identified. Postmortem CT (PMCT) and autopsy revealed that the cause of sudden death was airway obstruction/asphyxia by tuberculous massive airway hemorrhage. Identification of the cause of death facilitated a subsequent active contact investigation and led to prevention of secondary tuberculosis infection.     

A death due to perirenal hematoma complicating extracorporeal shockwave lithotripsy

Perirenal hematoma is an occasional complication of extracorporeal shockwave lithotripsy (ESWL) which does not usually require treatment. A 79-year-old woman died 23 h after ESWL. Forensic autopsy was performed to determine whether medical treatment contributed to her death. The cause of death was hemorrhagic shock due to massive hematoma from a ruptured small vein in the perirenal adipose capsule. No injury to other organs was found and the patient had neither coagulation abnormality nor venous disease. Perirenal hematoma can easily be diagnosed with abdominal sonography, if pain or symptoms of anemia develop. Doctors must be aware of the possibilities of severe renal hematomas after ESWL.     

Fatal Venous Air Embolism Following Intravenous Infusion*

Abstract: Venous air embolism has been reported as a complication of invasive diagnostic and therapeutic procedures or accidental trauma. Little is known about the incidence of air embolism after minimal intravenous manipulations such as the insertion of a peripheral intravenous cannula. Only when large amounts of air sufficient enough to block the cardiovascular system enter, the patient develops symptoms and signs of severe neurological injury, cardiovascular collapse, or death. The dead body of a 14‐year‐old boy was brought for postmortem examination with allegations of death from negligence during treatment. He was treated for pain in the abdomen in a hospital by attendants in telephonic consultation with a medical practitioner. Following intravenous infusions, the boy died suddenly in respiratory distress. Gross findings indicated the death to be from venous air embolism. Chemical analysis, histopathology, and microbiology ruled out other causes of death. Dilemmas of the case with difficulties in diagnosis are being presented herewith.     

Death from thermal effects and burns

One hundred and fifteen unselected autopsy cases of death from thermal effects and/or fire between 1990 and 1999 were analyzed with regard to time of death, signs of vitality at the scene of the fire, the manner and cause of death, and the extent of soft tissue loss. The cases represented approximately 6% of all autopsy cases at the Institute of Legal Medicine responsible for a catchment area with approximately 700,000 inhabitants. In 23 victims suffering burn injuries, death occurred during initial medical care or clinical treatment. The causes of death were primary respiratory arrest due to smoke poisoning or delayed shock caused by thermal injuries to the skin. Death occurred at the scene of the fatal event in 85 cases: eight cases exhibited no thermal effects; the cause of death in one of these cases was polytrauma incurred in a leap from a height; in seven cases there was poisoning due to smoke inhalation. The remaining 77 cases were characterized by signs of intensive thermal and/or fire effects. Clear signs of vitality (carboxyhemoglobin (COHb) in blood, inhalation and/or swallowing of soot) were found in 84.7% of the victims dying at the site of the fatal event. Of the 13 victims showing no signs of vitality at the scene, a cause of death could be determined in only seven cases; death in the other six cases remains unexplained. Quantification of the soft tissue loss revealed a possible correlation with the temperature and time course of heat exposure.     

Hyaluronidase as a liquefying agent for chemical analysis of vitreous fluid

Vitreous humor is a suitable specimen for postmortem clinical chemistry because the analytes remain relatively stable after death and they closely reflect blood levels immediately prior to death. The viscous nature of vitreous fluid, however, presents analytical problems including imprecision and inaccuracy. Various preanalytical treatments, such as boiling, high speed centrifugation, microfiltration and dilution have been used. These techniques are labor intensive and add to imprecision and inaccuracy. Because glycosaminoglycans contribute significantly to the viscosity of vitreous humor, we used hyaluronidase as a liquefying agent. We compared the results of analyses in 33 vitreous humor specimens after hyaluronidase treatment with the results after either no treatment or specimen dilution. Seventeen of the 33 specimens could not be analyzed without dilution. Even after dilution, several analytes still could not be measured. Hyaluronidase treatment negated the need for sample dilution and had no significant effect on the analyses.     

Karl Marx and the Death Penalty

This study is a Marxist analysis of capital punishment or the death penalty. The only detailed treatment of the subject by Marx appeared in an article published in the New York Daily Tribune, February 18, 1853, and that treatment was only a sketch. Thus, the following study is an attempt to suggest what a reading of Marx may contribute to an understanding of capital punishment. I conclude that abolition of the death penalty does not need a Marxist justification, but a Marxist justification adds to the many arguments for that course of action.     

A case of sudden death due to spontaneous coronary artery dissection

Spontaneous dissection of the coronary arteries is an extremely rare event that occurs usually in middle-aged women and is mostly recognized at postmortem examination in victims of sudden death. It is a rare coronary pathologic finding whose precise incidence, etiology, pathogenesis, treatment, and evolution have not been clearly established. We present a sudden death case of a 53-year-old woman with spontaneous dissection of the left anterior descending coronary artery with eosinophilic coronary arteritis.     

Additional disability or death due to hospital care, medical or surgical treatment, examination, or training and rehabilitation services--VA. Final rule

This document amends the Department of Veterans Affairs (VA) adjudication regulations concerning awards of compensation or dependency and indemnity compensation for additional disability or death due to VA hospital care, medical or surgical treatment, examination, or training and rehabilitation services. Under this final rule, benefits are payable for additional disability or death caused by VA hospital care, medical or surgical treatment, or examination only if VA fault or "an event not reasonably foreseeable" proximately caused the disability or death. Benefits are also payable for additional disability or death proximately caused by VA's provision of training and rehabilitation services. This final rule is necessary to reflect Congress' recent amendment of 38 U.S.C. 1151, the statutory authority for such benefits.     

Can we handle the truth? Legal fictions in the determination of death

Advances in life-saving technologies in the past few decades have challenged our traditional understandings of death. People can be maintained on life-support even after permanently losing the ability to breathe spontaneously and remaining unconscious and unable to interact meaningfully with others. In part because this group of people could help fulfill the growing need for organ donation, there has been a great deal of pressure on the way we determine death. The determination of death has been modified from the old way of understanding death as occurring when a person stops breathing, her heart stops beating, and she is cold to the touch. Today, physicians determine death by relying on a diagnosis of total brain failure or by waiting a short while after circulation stops. Evidence has emerged that the conceptual bases for these approaches to determining death are fundamentally flawed and depart substantially from our biological and common-sense understandings of death. We argue that the current approach to determining death consists of two different types of unacknowledged legal fictions. These legal fictions were developed for practices that are largely ethically legitimate but need to be reconciled with the law. However, the considerable debate over the determination of death in the medical and scientific literature has not informed the public of the fact that our current determinations of death do not adequately establish that a person has died. It seems unlikely that this information can remain hidden for long. Given the instability of the status quo and the difficulty of making the substantial legal changes required by complete transparency, we argue for a second-best policy solution of acknowledging the legal fictions involved in determining death. This move in the direction of greater transparency may someday result in allowing us to face squarely these issues and effect the legal changes necessary to permit ethically appropriate vital organ transplantation. Finally, this paper also provides the beginnings of a taxonomy of legal fictions, concluding that a more systematic theoretical treatment of legal fictions is warranted to understand their advantages and disadvantages across a variety of legal domains.     

Fatal Disseminated Cryptococcus as the Initial Presentation of HIV Infection in the Era of Highly Active Antiretroviral Therapy

Abstract:  Despite the availability of highly active antiretroviral treatment, many HIV-positive patients still present for the first time with a low CD4 count or an acquired immune deficiency syndrome (AIDS) defining illness. This may be due to patients' refusal to be tested for HIV, delay in seeking medical treatment, or the misdiagnosis of an AIDS-associated condition. We present a 39-year-old African American male with undiagnosed HIV, who died shortly after arrival to the emergency room. An autopsy was performed at the Dallas County Medical Examiners' Office, and the cause of death was determined to be disseminated cryptococcosis. Further investigation at autopsy revealed HIV 1/2 antibody positivity and HIV western blot positivity. This case demonstrates the importance of considering complications of HIV as a cause of death, even when the patient has no prior history.     

REASSESSING RACE DISPARITIES IN MARYLAND CAPITAL CASES*

A generation of research studies that were conducted in multiple states and covered different time periods has found evidence that individuals who kill white victims encounter a greater risk of facing the death penalty than killers of black victims. More recently, research has also examined the likelihood of death penalty processing for black defendants who kill white victims in comparison with other defendant–victim race groups. In particular, a study in Maryland conducted by Paternoster et al. (2003) found evidence that offenders in black defendant–white victim cases were more likely to be death noticed by prosecutors and to receive a death sentence than other offenders. A recent analysis by Berk, Li, and Hickman (2005) raised questions about some of these findings. In this article, we conduct new analyses and conclude that black defendants who kill white victims face a greater risk of adverse treatment than other types of defendants.     

Sudden death due to cerebral leukemic hemorrhage occurring after acupuncture treatment for gingival bleeding

A 45-year-old woman who experienced stomalgia and gingival bleeding for several days died unexpectedly after acupuncture treatment. At autopsy, trivial injuries on the liver and the stomach and mild hemoperitoneum due to improper acupuncture were found. Also,acute lymphoblastic leukemia and hyperleukocytosis were diagnosed by postmortem examinations. Intracranial hemorrhage due to undiagnosed acute lymphoblastic leukemia was identified as the cause of death.Moreover, the relationship between therapeutic misadventure and death was also determined. We suggest that undiagnosed leukemia should be considered as a differential diagnosis when sudden death occurs owing to intracranial hemorrhage. If therapeutic misadventure was involved,it is also of great importance to assess the relationship between that and death in forensic expertise.     

猝死与冠状动脉肌桥

冠状动脉肌桥临床上的表现,血管造影,诊断以及治疗得到医生的普遍认可,但在导致猝死尚还没有引起法医同仁的注意。通过复习相关的文献。本文主要对冠状动脉肌桥的研究状况、致死机制以及由此引起猝死的病理特点等进行阐述。     

Dirty diving. Sudden death of a SCUBA diver in a water treatment facility.

We report a case of a sudden death in a SCUBA diver working at a water treatment facility. The victim, an employee of the facility with a specialty in electronics, was a sport diver not qualified in commercial diving. While attempting to clean sludge from a blocked drain 25 ft under water, the diver was suddenly pinned against the drain valve when the sludge plug was broken up. We review the mechanics of the incident and the actual cause of death, asphyxia, as opposed to drowning. We believe this to be the first reported case of traumatic (pressure) asphyxia in a SCUBA diver.     

Rapid death from thrombotic thrombocytopaenic purpura following caesarean section.

We report a case of rapid death from thrombotic thrombocytopaenic purpura (TTP) in a young pregnant lady who developed full blown symptoms soon after caesarean section. Extensive intramyocardial confluent haemorrhages and widespread microthrombi in heart, brain, adrenals and kidney were found at autopsy. Thrombotic thrombocytopaenic purpura is an uncommon condition, which carries a high fatality rate if untreated. Awareness of this syndrome together with its high risk of sudden death underlines the importance of rapid diagnosis and treatment.